Posts Tagged ‘Case Studies’

Some time ago I set myself a goal to write up case studies based on the positive results that have I seen in my practice. Like every Chiropractor I get excited when I hear of life changing turnarounds in a wide range of health complaints. And not always because that person first consulted me with “Condition X” – they may come to me with the garden variety neck and back ailments. But then weeks later the person shares their story of healing and improved quality of life since starting to see me.

Well you might say I have opened a can of worms because the reality of “writing up” has been daunting: A clear history, examination findings and having some sort of outcome measure in place so that after those weeks of adjustments you can say for real that signs and symptoms have diminished – the objective before and after as opposed to the testimonial. And then there is the challenge of writing up an introduction and discussion of the condition in question – requires literature research and time.

So retrospectively I began to dig out files of my fondest case memories and quickly discovered that I did not have much more to go on than a testimonial. Child was a bed wetter – now they aren’t, teenager had reduced asthma medications and number and severity of attacks but no actual numbers to go along with those subjective observations, person who attended for low back pain and was then able to become pregnant after being adjusted (why didn’t they tell me they were infertile when they presented?), a parent stating that their child’s ADHD had significantly improved but now I have the challenge of finding out of their academic and social performance has improved – where to start?

I had been haunted by the words of an “old-timer” chiropractor at a Dynamic Growth Congress years before. He asserted that you “never ask your patients how they are – you tell them!” How do you do that? Now I know that we get to know our practice member’s bodies and that we can to a degree sense where they are at – but that intuition wasn’t quite enough for me – I wanted tools to measure where someone was in their functional journey. I’ve never been a dedicated user of Xrays and biomechanical lines and would always prefer non-invasive technologies so I began searching. The first purchase I made somewhere in the mid-nineties was software to analyse posture (www.torquerelease.com.au/Posture-Pro-Software.htm) and to come up with some objective calculations – cool tool and patients love the before and after pictures – a win-win. Back then this type of software cost thousands. This was in the days when computers were like old-age pensioners – took half the morning to warm up, and then didn’t do much after lunch. And we had to buy excessively expensive cameras that had a removable floppy disc – remember what those were? I envy today’s chiropractors who can pick up the latest version of this software for less than a grand, and download and install it on their high-speed notebook, and already have the camera that connects wirelessly.

Next I took out a five-year lease to get my hands on an Insight Subluxation Station (www.subluxation.net.au) and discovered that surface EMG, thermography and inclinometry were awesome tools for me to see if I was making the physiological changes that I hoped my adjustments produced. Boy was this confronting as I was forced along a pathway of finding better ways to deliver better adjustments and advice. I think we Chiropractors have had it too easy for too long because the only quality assurance that we have had to answer to is customer satisfaction. I remember one of my associate Chiropractors who was notorious for bypassing initial and progress exams, who when confronted stated that he didn’t see the point in using the measurements when they didn’t change! I guess my conclusion had been different as my revelation was that maybe I had to find the best ways for making positive changes – After all if a spine isn’t better aligned, more flexible and surrounded by less muscle tension after a series of adjustments, then what has been the actual benefit of those adjustments?

My next revelation was that I needed better outcome measures in my practice for a range of health concerns: If someone consults me and they suffer with migraines then I need to be able to demonstrate that the improvements in the sEMG, posture, thermography and range of motion are matched by measurable improvements in the regularity and severity of the signs and symptoms of migraine – sounds simple – just visit outcomemeasures.? to download the free tools I hoped? Not! My fantasy was a file of severity questionnaires that could be accessed depending on the name of the presenting dis-ease. So I contacted the academics and was told that such standardized and validated tools did exist. Next step was to find them… Still looking! Here’s the problem – they all have different completion and rating systems, most aren’t free or at least accessible, and regardless of whether they are scientifically validated few have been designed by chiropractors, for chiropractic – what is the point of a headache questionnaire that lacks a question about neck pain or dysfunction, or a low back questionnaire that fails to note any associated gastrointestinal or genitourinary signs? Since this time I have been gradually authoring my own range of health questionnaires – as I encountered a different health syndrome in practice, I would spend hours researching and then listing the “top twenty” associated signs and symptoms which would then be pasted into my template – each having exactly the same rating and format (www.torquerelease.com.au/Health-Questionnaires.htm) . Now these aren’t validated research tools but I love them for the power that they offer in terms of being able to take a subjective snapshot in time.

Nowadays I am in a newer practice and while designing my new systems I spent numerous hours (internet) searching for the best outcome tools out there: They had to be affordable, simple to use, and easy for the practice member to comprehend. After much shopping I combined Posture Pro, with digital photographic range of motion analysis software, Heart Rate Variability (www.torquerelease.com.au/emWave.htm) , along with the Torque Release Technique Indicators of Subluxation Scoring System that I had developed, and my Health Outcomes Questionnaires. Now I present my practice members with what I call their Spinal Functional Age (SFA) and Self-Perceived Health Age (SPHA).

The next barrier was in getting humans to follow the plan. I realised that my chances of producing legitimate case studies retrospectively were small. I needed to have a prospective plan: When Master Bedwetter, or Miss Asthma, or Mr Parkinsons or Mrs Multiple Sclerosis arrives at my rooms then I need the procedures in place so that I have sufficient pre-examination findings. Next challenge is to achieve sufficient compliance with care that will result in the types of positive changes we aspire to. And step three is to conduct a progress examination that supplies the “evidence” that I crave which is going to look good in ink.

What I am trying to say here is that my initial urge to write up a simple case study that is of some value to the evidence-base has actually sent me on a path of research and development that I like to think is making me a better Chiropractor.

Have you ever watched an episode of Geoffrey Robertson’s Hypothetical? This famous legal shark draws together a diverse cross section of “experts” and then forces them through a hypothetical case scenario that pushes the ethical, moral and human boundaries. Entertaining and usually enlightening viewing. To a point I believe it is valuable to apply this principle in our practice development pathway.

So, how does MY hypothetical influence YOUR life in practice? Ask yourself these questions:

1) Is your initial intake process thorough and objective enough that you could present clear evidence of what it is you are setting out to change for that person?

2) Do you have objective measurement tools to demonstrate how much this person’s functional status needs to change and whether you will have been able to initiate a change in their health concern?

3) Do you conduct a progress or review exam to measure whether you are achieving your shared goals?

4) Have you had the guts to put your technique to the objective litmus test across your entire practice population and not just your favourite miracle cases?

5) Do you have enough evidence to contribute a Case Study for the advancement of the Chiropractic Evidence Base?

When I present the stats from my own practice I show the average functional changes that occur and share the journey I have had to follow to ensure that I consistently generate significant objective improvements. At one seminar a Chiropractor pulled me aside during a refreshment break, and with a concerned look on his face stated that the changes I had documented were not very BIG. “Oh really” I said “how big are the changes that you are seeing?” “Well I don’t know” he said “but I know that they would be better than yours”. I almost envy his delusions of grandeur, but the reality is if you don’t know for sure, then you don’t know! My own research based on the functional tools that I currently prefer, suggest that one adjustment reduces someone’s functional age by one year. I personally think that is very significant – name any other healing method that can make someone one year younger in one visit?

The researchers sought to demonstrate that upper cervical specific adjustments would have a positive effect on the physiology, serology and immunology of HIV positive individuals.

Tests were performed on the patients by an independent medical center. The CD4 counts in the regular group were dramatically increased over the counts of the control group. A 48% increase in CD4 cells was demonstrated over the six month duration of the study for the adjusted group.

A small randomised, controlled clinical trial was carried out on two patient groups, each with 5 patients. The regular adjusted group was given upper cervical adjustments to the atlas using the Laney instrument, and for the control group a placebo adjustment was carried out by placing the stylus on the patients’ mastoid process with the instrument emitting no force.

The results are quite remarkable. In summary, the control group experienced a 7.96% decrease in CD4 cell levels and the adjusted group experienced a 48% increase in CD4 cell levels. It would be desirable to carry out follow up studies with far larger groups in an attempt to establish both a link between the nervous system, immune system and upper cervical region.

Super Healthy Tip…

I have seen a diverse number of research papers and case studies over the years which consistently illustrate improvements in immune function when chiropractic adjustments are received. My fairly black and white brain looks at it this way – chiropractic adjustments kick start the immune system. In my own practice if someone rings to cancel their appointment because they’ve “got the flu” – we try to insist that they keep their appointment – and repeatedly we have seen much quicker recoveries in the people who keep their appointments, than the ones who we are still ringing two weeks later to see if they are up to an appointment yet.

But how can this be – someone adjusting your spinal column – improving your immunity?

Consider the following:

Your spinal column houses your central nervous system

Direct nerve connections to immune system tissues have now been isolated

Many of the chemicals of communication found in rich deposits in the spinal cord, have receptor sites on many of the types of white blood cells – so even without direct nerve connections there must be a chemical communication process between the two systems

The key to a healthy immune response is dependent on the recognition and reaction to invading microbes – not only do the white blood cells that encounter a microbe need to know about it – they need to tell all the other white blood cells too – this needs a fully functional communication network – we know this as the nervous system

Malfunction in the spinal column could interfere with this communication network, and correction of this malfunction would therefore restore the network

There seems to be a progressively increasing number of practice guidelines appearing on the horizon for Chiropractors. If enough of these are generated could it get to the point that depending on whom a Chiropractor is dealing with, they will need to behave and practice in a chameleon-like fashion – what’s good for one patient, may be very different to what is good for another – depending on which guideline oversees that person’s situation?

Some of these guidelines appear to be less like best practice guidelines and more like agenda-based guidelines.

Most recently the Chiropractors Registration Board of Victoria has crossed over a boundary not previously entered into, and that is into the arena of clinical practice guidelines (http://www.chiroreg.vic.gov.au/comment.php). This is being justified on the basis that they act to protect the public against unethical chiropractice – but once reviewed against the standard of everyday chiropractic one might ask who will protect the chiropractor from the public and other third parties?

And if many established and widespread chiropractic practices such as X-raying for biomechanical assessment, use of physiological assessments such as surface EMG, adjusting children and newborns, caring for people with non-musculoskeletal conditions, maintenance and even wellness adjustments are guidelined as fringe, questionable and even unacceptable behaviours, then will future chiropractic practice resemble the service that so many chiropractors have offered to their communities for over 100 years?

Most of these guidelines are presented under the umbrella of “evidence-based practice”: Evidence-based clinical practice is defined as “The conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients… (it) is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.” (Sackett DL. Editorial. Evidence Based Medicine. Spine 1998.)

However it appears that some guideline developers twist the definition of “best” – disqualifying research and publication, or evidence, which isn’t the “best” – that is, if it isn’t a randomised, placebo-controlled, longitudinal, multi-centred, independently peer reviewed, published in a journal which the expert panel subscribes to, then it ain’t “best” and therefore it doesn’t exist…

In fact “best evidence” means the best level of evidence that we can find and what it tells us… If we don’t have the gold standard evidence, then do we have silver, bronze and even minor placing evidence to review and interpret? It is no secret that not only is chiropractic not very amenable to controlled study for a plethora of reasons, but the bulk of our evidence exists in the realm of longitudinal outcome studies, case series, and case studies. If this is the “best evidence” what does it tell us – there can be no denying that they tell us that a massive diversity of health complaints present in chiropractors’ offices, and that positive changes seem to happen?

We can’t say that if 100 “Syndrome A” sufferers present to chiropractic offices tomorrow, what percentage of these people will receive some degree of improvement let alone a complete resolution. But based on the evidence wouldn’t it be fair to say that if a “Syndrome A” sufferer presents to your office tomorrow, that it would be rational to initiate a course of treatment with clear goals and terms for review? How does that seem inferior or unacceptable to any other health care profession’s plan of action? Even after the gold standard research measures that 45% of patients receive an average of 35% improvement, what can we guarantee Mrs Jones on Monday morning? A course of care with clear goals and terms for review…

“Well it might mean that they aren’t receiving necessary medical intervention and maybe they have some terminal condition and detection will be delayed by this unproven approach!” Welcome to the life of a health care consumer trying to deal with a “primary care practitioner” – maybe the medications that the MD would prescribe as an “alternative” to our care would be ineffective or even damaging; may mask or delay the identification of other pathology; and maybe it could take months and even years to get a correct diagnosis in the medical system anyway? Sound familiar?

The chiropractic profession is not alone in the struggle to produce relevant and applicable guidelines which guide best practice, as opposed to restricting practice. “The National Health and Medical Research Council (NHMRC – an Australian Government body) has statutory responsibilities to raise the standard of individual and public health throughout Australia and to foster the development of consistent health standards. As part of this role, the NHMRC encourages the development of evidence-based guidelines by expert bodies.” (NHMRC standards and procedures for externally developed guidelines, updated September 2007)

Is a health care profession’s registration board an example of such an “expert body”? A quick read of the profiles of members of the board suggests that there is not much representation of the chiropractic profession’s academic and scientific community. So has the board received significant funding to employ the services of such experts? Who would know – no names or qualifications of any contributors or peer review panel members are listed in any of the guidelines. The guideline which covers the issue of paediatric care is an exception: It gives thanks to a Medical Paediatrician and an American Chiropractor who also holds Medical Degree, who is a self proclaimed “Quackbuster” who deals with healthcare consumer protection, and is therefore about quackery, health fraud, chiropractic, and other forms of so-Called “Alternative” Medicine (“sCAM”): Is this our desired expert body?

“It is now widely recognised that guidelines should be based, where possible, on the systematic identification and synthesis of the best available scientific evidence. The NHMRC requirements for developing clinical practice guidelines are rigorous so as to ensure that this standard is upheld. As such, guidelines with NHMRC approval are recognised in Australia and internationally as representing best practice in health and medical knowledge and practice.”

I’ll leave it to the educated reader to review the current proposed guidelines based on the following information:

Key principles for developing guidelines:

The nine key principles are:

1. The guideline development and evaluation process should focus on outcomes: This statement shouldn’t be glossed over as it seems that some of the worst examples of guidelines are more interested in practice than outcomes.

2. The guidelines should be based on the best available evidence and include a statement concerning the strength of recommendations. Evidence can be graded according to its level, quality, relevance and strength; (Ideally, recommendations would be based on the highest level of evidence. However, it has been acknowledged that the levels of evidence used by the NHMRC for intervention studies are restrictive for guideline developers, especially where the areas of study do not lend themselves to randomised controlled trials. It is proposed that this issue will be addressed when the toolkit publications are reviewed.)

It is tradition when presenting scientific evidence, to cite the source of your evidence. The proposed guidelines of the Registration Board list no references, and request for such evidence is refused on the grounds of “intellectual property”. Does this mean that there is no evidence? Is it only some “expert’s” opinion? Or are there too many pages of citations to fit in the publication? Who would know?

3. The method used to synthesise the available evidence should be the strongest applicable;

4. The process of guideline development should be multidisciplinary and include consumers early in the development process. Involving a range of generalist and specialist clinicians, allied health professionals and experts in methodology and consumers has the potential to improve quality and continuity of care and assists in ensuring that the guidelines will be adopted;

The board’s approach is to implement this step as late as possible, input only being sort after the guidelines have been drafted; and if past guidelines are representative, additional input will only lead to minor amendments at best.

That’s also why it is best to employ a medical paediatrician and an overseas chiropractor to produce a guideline on chiropractic care for children in Victoria. Perhaps the Australian chiropractic paediatric specialists that abound and the university academia that are responsible for the undergraduate paediatric curriculum were out to lunch when the document was written?

5. Guidelines should be flexible and adaptable to varying local conditions;

6. Guidelines should consider resources and should incorporate an economic appraisal, which may assist in choosing between alternative treatments;

7. Guidelines are developed for dissemination and implementation with regard to their target audiences. Their dissemination should ensure that practitioners and consumers become aware of them and use them;

In the case of the guidelines being discussed here you can download them from the web-site – otherwise you can get someone else to download them from the web-site for you.

8. The implementation and impact of the guidelines should be evaluated; and

9. Guidelines should be updated regularly. I look forward to the dissemination of the steps and process for implementation of steps 3 and 5 to 9 with our newest guidelines – don’t hold your breath.

So, if the Registration Board’s attempt to offer guidelines is severely flawed where can we turn?

Guidelines have been produced which would more likely live up to the standards of the NHRMC. The Council on Chiropractic Practice Clinical Practice Guideline (“CCP”) is currently undergoing its’ second revision. Following publication of the CCP Guidelines the document was submitted to the National Guideline Clearinghouse for consideration for inclusion. The NGC is sponsored by the U.S. Agency for Health Care Research and Quality and is in partnership with the American Medical Association and the American Association of Health Plans.

Its mission is as follows: “The NGC mission is to provide physicians, nurses, and other health professionals, health care providers, health plans, integrated delivery systems, purchasers and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use.” In other words the US equivalency of the NHRMC.

The AHRQ contracts with ECRI, a nonprofit health services research agency, to perform the technical work for the NGC. ECRI is an international nonprofit health services research agency and a Collaborating Center of the World Health Organization.

In November of 1998, following review by ECRI, the CCP Guidelines were accepted for inclusion within the National Guideline Clearinghouse.

The CCP has developed practice guidelines for vertebral subluxation with the active participation of field doctors, consultants, seminar leaders, and technique experts. In addition, the Council has utilized the services of interdisciplinary experts in the Agency for Health Care Policy and Research (AHCPR), guidelines development, research design, literature review, law, clinical assessment, chiropractic education, and clinical chiropractic.

The Council additionally included consumer representatives at every stage of the process and had individuals participating from several major chiropractic political and research organizations, chiropractic colleges and several other major peer groups. The participants in the guidelines development process undertaken by the CCP and their areas of expertise are clearly disclosed.

The Guidelines offer ratings of practices based on the following system:

Established: Accepted as appropriate for use in chiropractic practice for the indications and applications stated.

Investigational: Further study is warranted. Evidence is equivocal, or insufficient to justify a rating of “established.”

Inappropriate: Insufficient favorable evidence exists to support the use of this procedure in chiropractic practice.